essential health benefits next steps in colorado february 2, 2012 2012 health policy roundtables for...
TRANSCRIPT
Essential Health Benefits
Next Steps in Colorado
February 2, 2012
2012 Health Policy Roundtables for Legislators
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CHI is a trusted and leading source of credible health information for Colorado leaders. Our data and analysis is used to:• Inform policy• Contribute to effective implementation• Support state efforts to improve health
The Colorado Health Institute
Access Quality Value Prevention
2012 Health Policy Roundtables for Legislators
February 2nd: Essential Health Benefits
February 16th: Reining in Growth in Health Spending
March 1st: Cost Containment through Care Coordination
March 15th: The Boomer Challenge
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Welcome!
• Essential Health Benefits: The Big Idea• What Health Reform Says About Essential
Health Benefits• What This Means for Colorado
Today’s Discussion
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What’s At Stake?
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A Profile of a Community
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A New Clinic
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Medical Clinic and Cafe
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Pitkin County – One of Highest Rates of Uninsured
829,000Coloradans
16% of population (2011)
Up from 678,000Coloradans
14% of population (2008-2009)
Pitkin County
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Essential Health Benefits: The Big Idea
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Vending Machines and Health Insurance
1. What will the vending machine look like and how will it work?
2. What’s in the vending machine?
3. How big will the items be?
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Vending Machines and Health Insurance
1. What will the vending machine look like and how will it work?
2. What foods will we sell in the vending machine?
3. How big will the items be?
Defining essential health benefits
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“Defining the essential health benefits was always going to be one of the toughest issues policymakers would face in implementing the health reform law…
Nearly every segment of the health care industry has a stake in it.”
The Challenge of Defining Essential Health Benefits
-- Larry Levitt, Gary Claxton, and Karen PolitzThe Kaiser Family Foundation
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• The framers of the essential health benefit concept were trying to address the issue of underinsurance.
• In addition, they wanted to standardize benefits across plans and states.
Why Essential Health Benefits are Important
Where people have coverage but still spend a large proportion of their income on services that are not covered.
675,000 Coloradans were underinsured in 2011.
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What Health Reform Has To Say About
Essential Health Benefits
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What’s Really at Issue: Federal Reform
•The Individual Mandate
•“Severability”
2016: Where Will the Currently Uninsured Go?
Total Coloradans newly insured by 2016: 510,000Total Coloradans uninsured in 2016: 390,000
Source: Dr. Jonathan Gruber’s analysis for the Colorado Health Benefit Exchange
Impacted by essential
health benefits
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Who is Impacted by Essential Benefits in 2016?
Impacted Not impacted
Small firm employer sponsored insurance
340,000 Large firm employer sponsored insurance
2,370,000
Individual market (on
and off Exchange)
620,000 Individual market (grand-
fathered)
70,000
TOTAL 960,000 TOTAL 2,440,000
Source: Dr. Jonathan Gruber’s analysis for the Colorado Health Benefit Exchange
Essential health benefits will impact Medicaid for adults, but not for children.
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The ACA provides main concepts, without structure or guidelines.
What’s In the Law? Outlining EHB
Ambulatory patient services
Emergency services
Hospitalization
Mental health/substance abuse
Rehabilitative and habilitative services
Laboratory services
Prevention, wellness, chronic disease management
Pediatric services
Maternity care
Prescription drugs
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Which is the best value?
Monthly premium: $500
Plan 1
Covers 50% of Rx drugs
$30 co-pay for physician visit
$1,000 deductible
Covers 100% of Rx drugs
$0 co-pay for physician visit
$100 deductible
Covers 50% of Rx drugs
$30 co-pay for physician visit
$500 deductible
Plan 3Plan 2
Actuarial value =70%
Actuarial value =80%
Actuarial value =90%
Monthly premium: $1,000
Monthly premium: $750
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What’s In the Law? Four Benefit Categories
Platinum plans cover 90% of benefit costs.
Gold plans cover 80% of benefit costs.
Silver plans cover 70% of benefit costs.
Bronze plans and cover 60% of benefit costs.
All provide EHB and have out-of-pocket limits equal to HSA law
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• HHS commissions Institute of Medicine report – October 2011• Should reflect plans in small
employer market• National premium target• Encouraged flexibility across states• Recommended public input
• HHS holds stakeholder sessions to gather input
The Approach HHS Took to Define EHB
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IOM Report: Policy Foundations
Economics Ethics
Evidence-based
practice
Population Health
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• States can choose from 4 benchmark plans:1. One of the three largest small group plans *2. One of the three largest state employee health
plans3. One of the three largest federal employee health
plan options4. The largest HMO plan offered in the commercial
market
What We Got: A Bulletin Leaving It Up To Colorado
* Option recommended by HHS24
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What This Means for Colorado
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The Big Balancing Act
Comprehensiveness of services
Cost
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Phase 1:Selecting A State Essential Health Benefit Plan
Ambulatory Services
Emergency Services
Hospitalization
Maternity and Newborn Care
Mental Health and Substance Abuse
Prescription Drugs
Rehabilitation and Habilitative Services
Laboratory Services
Preventive and Wellness Services
Pediatric Services Including Oral and Vision
Ambulatory Services
Essential Health Benefit Required Categories
State Benchmark Plan
Emergency Services
Hospitalization
Maternity and Newborn Care
Mental Health and Substance Abuse
Prescription DrugsRehabilitation and
Habilitative Services
Laboratory Services
Preventive and Wellness Services
Ambulatory Services
Pediatric Services
Pediatric Oral and Vision
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Many State Mandates Fit Within 10 Categories
Emergency Services
Hospitalization
Maternity and Newborn Care
Mental Health and Substance Abuse
Prescription Drugs
Rehabilitation and Habilitative Services
Laboratory Services
Preventive and Wellness Services
Pediatric services Including Oral and Vision
Ambulatory Services
Essential Health Benefit Categories
•Newborn Coverage•48 hour hospitalization after birth•96 hour hospitalization after C-section•Cleft palate•Medical food for inherited disorders•Autism Spectrum Disorders•Congenital Anomalies and Defects•Complications of pregnancy and childbirth•Maternity Care•Hospice and home health coverage•Alcoholism treatment•Prostate cancer screening•Diabetes care and equipment•Mental health parity
Which categories do these fit in?
DOI: there are 34 state mandates on health insurance benefits as of 1/1/2012 28
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Emergency Services
Hospitalization
Maternity and Newborn Care
Mental Health and Substance Abuse
Prescription Drugs
Rehabilitation and Habilitative Services
Laboratory Services
Preventive and Wellness Services
Pediatric services Including Oral and
Vision Care
Ambulatory Services
Phase 2: Decisions About Specific Services and Cost sharing
Limits to hospital days?
Limits on number of therapy visits?
Limits on types and number of oral health visits?
HHS will be releasing additional guidance on cost sharing.
Women’s health services?
Behavioral health treatment?
In-patient rehabilitative services?
• Pediatric dental and vision care• Bariatric issues• Hearing aids• In Vitro fertilization• Autism: Applied behavior analysis therapy• Habilitative services• Behavioral health and substance abuse
Where is there variation across markets?
Key issues in Colorado
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Scope of benefits within each category?
Controlling costs by limiting visits?
Separate benchmarks for individual and small group?
State mandates re-evaluated in 2016?
Questions at Hand
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Jan
Feb
March
April
May
June
July
Aug
Sept
Oct
Nov
Dec
The Road Ahead: 2012
COHBE & DOI submit comments
to HHS(January 31)
Final decision due to insurance plans
(Quarter 3)
Stakeholder meetings held by COHBE & DOI
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2013
2014
2015
2016 & later
The Road Ahead: 2013 and Beyond
2014 - 2015Federal government covers
difference between Colorado mandates and federal mandates
2016Colorado may be
required to cover cost of difference between state
& federal mandates
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• DOI and COHBE will host forums to inform and receive public comments
• DOI & COHBE not pushing legislation in 2012• Important issue for constituents
and stakeholders across Colorado
How We’re Going to Have This Discussion
HHS Secretary Kathleen Sebelius at a stakeholder meeting in Denver in November 2011.
Source: Health Policy Solutions
Reining in Growth in Health Spending• What are the drivers of health care cost growth in Colorado?• What can be done to address cost drivers? • What’s happening in Colorado?
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Next Event: February 16th
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Michele Lueck 720.382.7073 [email protected]
Source: The Henry M. Rhoads Photograph Collection, Denver Public Library Digital Collections